Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children
Swedish Surgical Society · 2025 · Sweden
Source and licence
- Authors
- Martin Salö, Catarina Tiselius, Anders Rosemar et al.
- Title
- Swedish national guidelines for diagnosis and management of acute appendicitis in adults and children
- Journal
- BJS Open, 2025
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC11980984
Licence statement of the original publication
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Suspected appendicitis in the primary care setting
- The decision whether the patient should be referred to an emergency department should be based primarily on history, clinical examination, and CRP (⊕).
- Scoring systems without acute blood tests seem promising to risk-stratify children in primary care for further management decisions (⊕).
Laboratory investigations
- When appendicitis is suspected, blood tests including leucocytes, neutrophils, and CRP should always be taken (⊕⊕⊕⊕).
- An electrolyte panel should be made on admission, partly for possible correction before anaesthesia, and partly because hyponatraemia is a good marker of complicated disease, especially in children (⊕⊕).
Scoring systems
- Scoring systems provide objective support for assessing the likelihood of appendicitis and should always be used. This strategy enables risk-stratified management for optimal resource utilization with fewer admissions, less use of imaging, and fewer operations (⊕⊕⊕⊕).
- The AIR (Appendicitis Inflammatory Response) score has been shown to provide reproducible results for all ages and should be the first choice (⊕⊕⊕⊕).
Diagnostic imaging
- Radiological diagnosis is particularly relevant in patients at intermediate risk of appendicitis (⊕⊕⊕⊕), where the diagnosis is unclear, or other important differential diagnoses are likely (⊕⊕).
- Ultrasound is the first choice, especially for examining children and pregnant women (⊕⊕).
- Abdominal CT is the second choice, has slightly higher specificity and sensitivity but is associated with radiation risk, even if it is small, so there should be a clear indication for examination (⊕⊕).
- Low-dose CT with contrast has similar accuracy as conventional CT (⊕⊕⊕⊕).
- MRI has much lower availability and should only be used for pregnant women where ultrasound has been inconclusive (⊕⊕).
Diagnostics in pregnant women
- When appendicitis is suspected in pregnant women, blood tests including leucocytes, neutrophils, CRP, and a urine sample should always be taken (⊕⊕).
- Ultrasound is the first choice (⊕), followed by MRI if available (⊕⊕⊕).
- Observation with repeated blood tests and ultrasound in cases of suspected appendicitis is reasonable if the woman is not otherwise unwell. This does not appear to affect maternal or fetal outcome (⊕).
- If US is inconclusive or if US and MRI are not available or would significantly delay the diagnosis, CT may be indicated if there is a sufficiently strong suspicion of complicated appendicitis unless the general condition is so affected that there is an indication for urgent surgery (⊕⊕).
- Diagnostic laparoscopy seems safe when it comes to preterm birth and fetal loss at least in early pregnancy (<20 weeks). However, the published evidence of the risk versus benefits is very limited and conflicting (⊕).
Antibiotic prophylaxis and postoperative antibiotics
- A dose of broad-spectrum antibiotics should be given as prophylaxis for appendectomy (⊕⊕⊕⊕).
- No postoperative antibiotics should be given in surgery for uncomplicated appendicitis (⊕⊕⊕⊕).
- Postoperative antibiotics should be given after surgery for complicated appendicitis. The definitions of gangrenous and perforated appendicitis vary widely, making studies difficult to interpret. There is probably no benefit from postoperative antibiotic treatment in gangrenous appendicitis (⊕⊕), but due to the uncertainty of the evidence, a 24-h postoperative antibiotic is recommended.
- Postoperative antibiotics should be given after surgery for perforated appendicitis, especially if adequate source control has not been achieved. Start antibiotic treatment immediately upon suspicion and continue for 3–5 days after surgery (⊕⊕⊕⊕). Treatment can be switched to an oral option as soon as clinically feasible (⊕⊕⊕).
Thrombosis prophylaxis
- Thrombosis prophylaxis is not routinely recommended in surgery for acute appendicitis.
- If the patient is over 40 years old and the operation lasts longer than 60 min, thrombosis prophylaxis should be considered.
- Thrombosis prophylaxis should be administered to patients with clear risk factors for thrombosis, including pregnancy.
Surgical treatment
- In assumed complicated appendicitis (not abscess and phlegmon), patients should be optimized and operated within 6 (–8) h for the sake of well-being and to reduce the risk of complications (⊕⊕).
- In assumed uncomplicated appendicitis, the risk of complications is not increased by up to 24 h from arrival at the emergency department to surgery (⊕⊕⊕⊕).
- Laparoscopic appendectomy is recommended as the first choice for all patient groups and for both uncomplicated and complicated appendicitis (not abscess and phlegmon) (⊕⊕⊕⊕).
- The standard three-port technique for laparoscopic appendectomy is recommended for both adults and children (⊕⊕).
- Open appendectomy may need to be used in late pregnancy and in case of contraindication to laparoscopy, but it is always a matter of judgement in each case.
- In complicated appendicitis with free fluid in the abdomen, aspiration of the fluid is recommended but not peritoneal lavage (⊕⊕⊕).
- Postoperative abdominal drain is not recommended (⊕⊕⊕⊕).
Primary treatment of abscess or phlegmon with antibiotics
- Patients with appendicitis abscess should be treated primarily with intravenous antibiotics and drainage. Phlegmon should be treated primarily with intravenous antibiotics (⊕⊕⊕⊕).
- Planned interval appendectomy after conservatively treated abscess or phlegmon is not routinely recommended except in cases where malignancy is suspected and/or unclear findings at follow-up remain (⊕⊕).
- Patients who have been treated conservatively for appendicitis abscess or phlegmon should be followed up with CT or colonoscopy (sometimes a combination of both) as there may be an underlying malignancy. This applies especially for patients aged over 40 years.
Primary treatment of uncomplicated appendicitis with antibiotics
- In two randomized trials, antibiotic treatment was not significantly better than placebo and therefore cannot be recommended for the treatment of uncomplicated appendicitis (⊕⊕⊕⊕).
Nursing care
- The enhanced recovery after surgery (ERAS) concept speeds up recovery, shortens hospitalization time, and seems to lead to fewer reoperations (⊕⊕⊕).
- Children who have undergone laparoscopic appendectomy for uncomplicated appendicitis can be discharged from hospital on the same day (⊕⊕).
- Urinary catheters and central access are not indicated in children with complicated appendicitis (⊕⊕).
- Pain relief for children at home usually consists of paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs).
Follow-up after treatment of appendicitis
- PAD should be made routinely in all patients (⊕⊕). If the resources are scarce, all appendices in patients >40 years of age should undergo PAD to avoid missing an alternative diagnosis. To evaluate the quality of the clinic, all consecutive appendectomy specimens should be analysed at least for a period of time
- Follow-up is not necessary if PAD shows acute appendicitis.
Follow-up after conservative treatment of appendicitis abscess or phlegmon
- Children do not need follow-up.
- People under 40 years of age do not require follow-up unless their medical history suggests a malignant genesis.
- People over 40 years of age are recommended to have a CT colonography or colonoscopy after 6–8 weeks to rule out malignancy (⊕). The findings on the abdominal CT scan can guide the selection of the most appropriate test.
- ○ the patient has recurrent appendicitis symptoms (relapse)
- ○ malignancy is suspected at follow-up.
Abstract
Background: Acute appendicitis is one of the most common causes of acute abdominal pain. Differences in the management of this large group of patients has important consequences for the patients and the healthcare system. Controversies regarding the understanding of the natural course of the disease, the utility of new diagnostic methods, and alternative treatments have lead to large variations in practice patterns between centres. These national guidelines present evidence-based recommendations aiming at a uniform, safe and cost-efficient management of this large group of patients.
Method: A working group of six experts with broad clinical and research experience was formed. Additional expertise from outside was consulted during the process. A national survey revealed significant variations in the management of patients with suspicion of appendicitis. The evidence provided in published guidelines and reviews were extracted and systematically graded, according to the GRADE methodology. This was supplemented by additional more recent and more directed search of the literature. Patients treated for appendicitis were involved through interviews. The guidelines were reviewed by external experts before the final version was determined.
Results: The guidelines cover an extensive number of issues: pathology, epidemiology, aetiology, natural history, clinical and laboratory diagnosis, diagnostic scoring systems, diagnostic imaging, treatment, nursing care, follow-up, quality registers and quality indicators, among others. Special considerations related to children and pregnant women are covered.
Conclusion: These national guidelines present an extensive and thorough review of the current knowledge base related to appendicitis, and provide up-to-date evidence-based recommendations for the management of this large group of patients.
Contents of the original publication
The section headings of the original.
- Introduction
- Methods
- Working group
- Guidelines development
- Background and causes
- Pathology and classification
- Diagnosis codes
- Epidemiology
- Aetiology and heredity
- Natural history
- Primary prevention and screening
- Diagnosis
- Triage
- Symptoms
- Clinical findings
- Children
- Differential diagnoses
- Laboratory investigations
- Observation with repeat examination
- Scoring systems
- Diagnostic imaging
- Ultrasound
- Abdominal CT
- Magnetic resonance imaging
- Diagnosis of appendicitis in pregnant women
- Appendicitis in pregnant women
- Diagnostics in pregnant women
- Treatment
- Preoperative optimization
- Antibiotic prophylaxis and postoperative antibiotics
- Thrombosis prophylaxis
- Surgical treatment
- Primary treatment with antibiotics
- Primary treatment of abscess or phlegmon with antibiotics
- Primary treatment of uncomplicated appendicitis with antibiotics
- Nursing care
- ERAS
- Children
- Pregnant women
- Follow-up after treatment of appendicitis
- Objectives of the follow-up
- Follow-up after appendectomy
- Follow-up after spontaneously resolved appendicitis
- Follow-up after conservative treatment of appendicitis abscess or phlegmon
- Long-term outcomes following surgery for acute appendicitis
- Follow-up responsibilities
- Quality registers and quality indicators
- Available registers
- Quality indicators and target levels
- Discussion
- Contributor Information
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